fever in the tropics tom d. thacher, md department of family medicine mayo clinic, rochester,...
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Fever in the Fever in the TropicsTropics
Tom D. Thacher, MDTom D. Thacher, MDDepartment of Family MedicineDepartment of Family Medicine
Mayo Clinic, Rochester, MinnesotaMayo Clinic, Rochester, Minnesota
[email protected]@mayo.edu
Fever as a SymptomFever as a Symptom
1.1. MalariaMalaria
2.2. HypertensionHypertension
3.3. DyspepsiaDyspepsia
4.4. Pulmonary Pulmonary tuberculosistuberculosis
5.5. Medical Medical examinationexamination
6.6. Upper respiratory Upper respiratory infectioninfection
7.7. Urinary tract Urinary tract infectioninfection
8.8. HIV infectionHIV infection
9.9. Diabetes mellitusDiabetes mellitus
10.10.PIDPID
1/3 of all presentations in primary care1/3 of all presentations in primary care
Disease Burden by Region
0%
20%
40%
60%
80%
100%
Africa SE Asia Americas
Injuries
Non-communicable
Communicable
Learning ObjectivesLearning Objectives
1.1. Syndromic ApproachSyndromic Approach
2.2. 8 Febrile Syndromes8 Febrile Syndromes
Context of FeverContext of Fever• AgeAge
• GeographyGeography
• SeasonSeason
• Duration of feverDuration of fever
• MalnutritionMalnutrition
• Immune statusImmune status
• ExposuresExposures
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
Which of these is NOT in the top Which of these is NOT in the top five causes of death in children in five causes of death in children in
tropical countries?tropical countries?
A. B. C. D. E.
38%
14%
6%
19%22%
A.A. MeaslesMeasles
B.B. PneumoniaPneumonia
C.C. TyphoidTyphoid
D.D. HIVHIV
E.E. MalariaMalaria
Malaria21%
Pneumonia17%
Diarrhea12%
HIV9%
Measles8%
Perinatal15%
Other18%
Causes of Death in Children Under Age 5 Years in Africa
2/3 of all2/3 of allchild deathschild deaths
1.1. Fever AloneFever Alone
• MalariaMalaria
• Typhoid feverTyphoid fever
• HIVHIV
• DengueDengue
• LeptospirosisLeptospirosis
• RickettsiaRickettsia
• Relapsing feverRelapsing fever
• Other viral illnessesOther viral illnesses
Symptoms of malariaSymptoms of malaria
• HeadacheHeadache
• PallorPallor• Severe hemolytic anemiaSevere hemolytic anemia• Heart failureHeart failure
• Cerebral malaria – impaired mental Cerebral malaria – impaired mental status, convulsions, comastatus, convulsions, coma
• Labored breathingLabored breathing• acidosis, heart failureacidosis, heart failure
• SplenomegalySplenomegaly
TyphoidTyphoid
• Sustained high Sustained high fever, headachefever, headache
• Apathy, psychosisApathy, psychosis
• Constipation, Constipation, abdominal painabdominal pain
• SplenomegalySplenomegaly
• Positive blood Positive blood cultureculture
www.worldortho.med.usyd.edu.au www.worldortho.med.usyd.edu.au
DengueDengue
• Asia, So. AmericaAsia, So. America
• Marked myalgia, eye painMarked myalgia, eye pain
• RashRash
• ↓ ↓ WBC, ↓ plateletsWBC, ↓ platelets
LeptospirosisLeptospirosis
• RashRash
• Aseptic meningitisAseptic meningitis
• Clue: conjunctival injection Clue: conjunctival injection
RickettsiaRickettsia
• Fever, headache, and myalgia Fever, headache, and myalgia
• Clue: tick exposure, painless escharClue: tick exposure, painless eschar
• African tick-bite fever, scrub typhusAfrican tick-bite fever, scrub typhus
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
2.2. Neurologic SyndromesNeurologic Syndromes
Fever, headache, altered mental Fever, headache, altered mental status, convulsions, comastatus, convulsions, coma
• Cerebral malariaCerebral malaria
• MeningitisMeningitis
• EncephalitisEncephalitis
• HIVHIV
EncephalitisEncephalitis
• RabiesRabies
• Japanese encephalitisJapanese encephalitis
• West Nile encephalitisWest Nile encephalitis
• Trypanosomiasis (sleeping sickness)Trypanosomiasis (sleeping sickness)
HIVHIV
• Chronic Meningitis: TB, cryptococcalChronic Meningitis: TB, cryptococcal
• ToxoplasmosisToxoplasmosis
• HIV dementiaHIV dementia
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
3.3. Abdominal SyndromesAbdominal Syndromes
Fever, abdominal painFever, abdominal pain
• TyphoidTyphoid
• Infectious colitis: shigella, E. coli, Infectious colitis: shigella, E. coli, salmonella, campylobacter, amebasalmonella, campylobacter, ameba
• Amebic liver abscessAmebic liver abscess
• Abdominal TBAbdominal TB
• Appendicitis, pyelonephritisAppendicitis, pyelonephritis
• HIVHIV
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
4.4. Pulmonary SyndromesPulmonary Syndromes
Fever, cough, dyspneaFever, cough, dyspnea
• PneumoniaPneumonia
• TuberculosisTuberculosis
• HIVHIV
Malaria21%
Pneumonia17%
Diarrhea12%
HIV9%
Measles8%
Perinatal15%
Other18%
Causes of Death in Children Under Age 5 Years in Africa
IMCIIMCIIntegrated Management of Childhood IllnessIntegrated Management of Childhood Illness
• Increased respiratory rateIncreased respiratory rate• ≥≥60 if age < 2 mos.60 if age < 2 mos.• ≥≥50 if age 2-12 mos.50 if age 2-12 mos.• ≥≥40 if age 12 mos. to 5 years40 if age 12 mos. to 5 years
• Lower chest retractionsLower chest retractions
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
5.5. Rash SyndromesRash Syndromes
Fever and skin rashFever and skin rash
• MeaslesMeasles
• HIVHIV
• DengueDengue
• Other virusesOther viruses
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
6.6. Hemorrhagic SyndromesHemorrhagic SyndromesHematemesis, melena, epistaxis, petechiae, Hematemesis, melena, epistaxis, petechiae,
purpura, puncture site bleedingpurpura, puncture site bleeding
• Ebola, Lassa, MarburgEbola, Lassa, Marburg
• Yellow feverYellow fever
• DengueDengue
• Relapsing feverRelapsing fever
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
7.7. Musculoskeletal SyndromesMusculoskeletal Syndromes
Fever with joint or bone painFever with joint or bone pain
• Sickle cell diseaseSickle cell disease
• Septic arthritisSeptic arthritis
• OsteomyelitisOsteomyelitis
• PyomyositisPyomyositis
• Rheumatic feverRheumatic fever
88CommonCommon
FeverFeverSyndromesSyndromes
1.1. Fever aloneFever alone
2.2. NeurologicNeurologic
3.3. AbdominalAbdominal
4.4. PulmonaryPulmonary
5.5. RashRash
6.6. HemorrhageHemorrhage
7.7. Bone and jointBone and joint
8.8. GynecologicGynecologic
8.8. Gynecologic SyndromesGynecologic Syndromes
Fever, pelvic pain, vaginal Fever, pelvic pain, vaginal dischargedischarge
• PIDPID
• Tubo-ovarian abscessTubo-ovarian abscess
• Postpartum endometritisPostpartum endometritis
• Septic abortionSeptic abortion
Treatment Limiting FactorsTreatment Limiting Factors
• Self treatment with OTC antibioticsSelf treatment with OTC antibiotics
• Limited spectrum of antibioticsLimited spectrum of antibiotics
• No health insuranceNo health insurance
• Counterfeit drugs and adulterationCounterfeit drugs and adulteration